EMS, Mass Casualty Management

Introduction

A mass casualty incident (MCI) is defined as “an event that overwhelms the local healthcare system, where the number of casualties vastly exceeds the local resources and capabilities in a short period of time.” Any MCI can rapidly exhaust available resources for not only the MCI but the normal day-to-day tasks of the hospital. Each hospital should institute a surge plan in preparation for anticipated, progressive, insidious ("notice" events), and sudden onset ("no-notice" events) disasters occurring within the community.

First and foremost in responding to an MCI is identifying the type of MCI present. Categories include:

Planned (sporting event)

Conventional, which usually have some level of recurring frequency (transportation incidents, burn, and severe weather events)

Chemical, biological, radiological

Nuclear agents from an unintentional or accidental release or act of terrorism

The keys in successfully managing the chaos of a fast-paced, moving MCI can be delineated with the organization of the 5 “S's”: “scene safety assessment, scene size-up, send information, scene set-up, and START.”

Clinical Significance

Activation of an MCI

Those deemed as having the capacity to declare the activation of an MCI may differ amongst different county and state protocols within the United States. However, it is fairly universal that Incident Command and local hospitals have the authority to declare and MCI. Most regions are flexible in this regard, allowing public safety agencies with jurisdiction of overseeing incident scene management, emergency management services (EMS) personnel who arrive first on the scene, Central Medical Emergency Dispatch (CMED), hospitals, and regional council staff to declare MCI to engage immediate early action.

Communications and Incident Management

The ability to successfully allocate resources and organize an effective response to an MCI is centered on flexible, integrated communication, and information systems. A command center should be organized and equipped with multiple radios tuned into separate frequencies that are “uninterrupted by a priority scan frequency lock-out,” which has shown to be effective. Each scene commander should be equipped with headsets, microphones, and clipboards, and checklists to enable continuous feedback to command regarding scene dynamics.

On Scene Control

The extent of an MCI is not solely dependent on the total number of created potential patients, but is exacerbated by other complicating factors coined “MCI Multipliers.” MCI Multipliers can range from limited scene accessibility, biohazard contamination, self-deploying responders not equipped or experienced for the current scenario, lack of on-scene or surrounding hospital resources, etc. A.J. Heightman, Editor and Chief of JEMS developed a table of “Multipliers that Affect MCI’s” that should be identified and managed as early as possible in the course of an MCI, and are listed below:

Physical location and access/egress complications

A number of access points and distance between exits on a highway

Location, speed, and density of traffic

Weather or roadway conditions

Time of day

Staffing levels

Massive debris field

Other simultaneous incidents that drain available resources.

Location of specialty teams and resources

Ambulances are unfamiliar with a district’s MCI operational procedures

Ambulances from another system arriving on the scene, or self-dispatching

Failure to establish incident command, divisions or groups early enough

Lack of scene vests or identification of triage, treatment or transportation areas

Late or improper access directions or staging instruction to incoming units

Complicating factors, such as ongoing crashes, gunfire or explosions

To combat these roadblocks, early on scene role establishment is essential.

Hierarchical Approach

Response and management to an MCI are dependent on hierarchy. Operations of the entire MCI are controlled by the Incident Commander of the National Incident Management System (NIMS) Incident Command System (ICS). Multidisciplinary Regional Medical Coordinating Systems (RMCCs), where available, meet to coordinate the transfer of patients during patient surges when the nearest facilities demands exceed their resources. RMCCs coordinate hospital resources based on the amount of emergent and non-emergent patient surges that each surrounding facility can accommodate.

Once on scene, the EMS Branch Director or the Incident Command (IC) is responsible for overseeing all on-scene operations (safety, scene size-up, communications, and so forth), which should be established early. While law enforcement is responsible for maintaining the security of the scene, the Safety Officer is responsible for assessing current and potential hazards maintaining responding crews’ safety. The Radio Officer works directly with incident command in providing frequently updated scene reports and coordinating communications with the Transportation Officer to local hospitals’ in assessing their ability to accommodate their ongoing needs. The Medical Supervisor must oversee and coordinate the triage, treatment and transport sectors of the scene; in essence, they are responsible for creating patient flow and managing patient resource allocation. The Triage Officer coordinates patient flow to the transportation area based on their designated clinical condition designated by the triage team. They are in charge of performing a final scene sweep to ensure no patient that has been rescued has been left without being triaged. The Treatment Officer establishes the treatment zone and allocates supplies. They are responsible for anticipating resource needs and updating the Transportation Officer of the number of “green, yellow, red, and black” triage designations and when those numbers change based on patients’ worsening clinical condition. The Transportation Officer is responsible for patient tracking, transportation assistance from local responding units, directions, and hospital designations based on resource availability and needs.

Mutual aid ambulance services, first responder units, and EMS personnel provide transportation and evacuation of MCI patients as dispatched per the established regional policy and communications center. Individual EMS personnel are prohibited from self-dispatch to the scene. The first available responder squad on the scene should be responsible for gauging the extent of the catastrophe, providing a scene report and alerting nearby hospitals for determination of resource and bed availability at those facilities. To quickly and efficiently gauge the extent of the MCI, the Massachusetts Department of Public Health recommends employing the “METHANE” mnemonic, and is as follows:

M: Major incident declaration

E: Exact location; the precise location of the incident, staging area, if applicable

Type of incident; the nature of the incident, including how many vehicles, buildings, and so forth are involved

H: Hazards; both present and potential

A: Access; best route for emergency services to access the site, or obstructions and bottlenecks to avoid

N: Numbers; of casualties, dead and injured on scene

E: Emergency services; which services are already on scene and which are still required (MCI trailer, Regional EMS Council staff, Task Force, and so forth)

Scene identification vests should be distributed to the IC, Safety Officer, Staging Officer, Medical Supervisor, Radio Officer, Triage Officer, Treatment Officer, Transportation Officer, and all rescue and responder personnel, branding them in their roles to be easily identified by the current on-scene personnel, newly incoming crews, and MCI victims. In the event of a terrorist-based MCI, ballistic tactical vests should be highly considered for distribution.

On scene, determine safe areas that can serve as a staging area, a specialty vehicle loading zone, a triage and a treatment zone that are removed from the scene of the accident or “hot zone,” and secure these areas with a police command. In addition, create a region for a morgue that is out of the way of but remains easily accessible for temporary body disposal and later removal from the scene. To continuously direct patient triage without necessitating the designation of a worker to remain in the staging area, stage the triage zones with color-coded green, yellow and red tarps to delineate minor, delayed, and immediate care zones, respectively. Not only will this tactic free up available first responder resources, it will allow the remaining walking wounded on the scene to locate emergency medical personnel.

Specifically, with regards to MCIs created by a mass shooting, more than 250 people had been killed over a 14 year period from 1999 to 2013. In response, the American College of Surgeons and the Federal Bureau of Investigation (FBI) in Hartford, Connecticut, gathered to create an efficient set of critical actions to be employed on the scene to maximize survivability of mass shootings. These critical actions were summarized within acronym THREAT:

Allocation of resources is based on the difficult decisions of patient triage. The START (Simple Triage and Rapid Treatment) adult algorithm constitutes the basis of MCI triage. In total, there are four categories in START: minor (green), delayed (yellow), immediate (red), and expectant (black). All patients should be tracked with START Triage Tags. The color designating the patient’s clinical condition is the color remaining after tearing off the other colors that do not match the patient’s condition. Persons that can be tagged green for “Minor” injuries are known as the “walking wounded”: they have relatively minor injuries, are unlikely to deteriorate over days and may be able to assist in own care. Those triaged to the “Delayed” category are those with potentially serious and life-threatening injuries. However, these patients should be able to follow simple commands, have capillary refill under two seconds, and respiratory rate is under 30 breathes per minute. Their status is not expected to deteriorate significantly over several hours, and transport can be delayed on this basis. Persons triaged into the “Immediate” category require immediate transportation and requires medical attention within minutes for survival (up to 60 minutes) for compromised airway, breathing, and circulation.These patients meet “Immediate” care criteria if they have respirations over 30 breaths per minute, signs of active hemorrhage, capillary refill over two seconds, or have altered mental status in which they cannot follow simple commands. Expectants are those who are dead or inevitably dying, and are triaged as “Black.” A jaw thrust maneuver may be implemented to determine if spontaneous respirations resume. If not, palliative medications only should be provided.

Inventory

Inventory of resources is as paramount resource allocation. Inventory methods should be adaptable and scalable. Both on the scene or in the hospital setting, inventory lists can be created on paper or electronic spreadsheet. The Incident Resource Inventory System (IRIS) provided by FEMA at no cost is a standards-based information software tool that “allows users to identify & inventory their resources, consistently with NIMS resource typing definitions, for mutual aid operations based on mission needs and each resource’s capabilities, availability and response time, and share information with other agencies.”